Family Planning Promotion in the Arab World:
Practices Perceptions and the Effectiveness of Birth
Spacing Campaigns in Amman
By
Brittany Buchholz
Family Planning Promotion in the Arab World: Practices, Perceptions
& the Effectiveness of Birth Spacing Campaigns in Amman
Introduction
Today, the nation of Jordan faces two major threats to the overall health and social well
being of its population. One threat is due to the Kingdom’s unsustainable annual population
growth rate of 2.6%, the result mainly of high fertility rates.1 A second threat, posed by
inadequate birth intervals and the lack of family planning, endangers women’s and children’s
health. Research has shown that spacing births less than two years apart may compromise the
development of the child and the ability of the mother’s body to replenish the nutrients needed
during pregnancy.2 New evidence shows that birth intervals of three to five years—well above
national averages in Jordan—are the healthiest options for both mother and child. Clearly,
efforts at both the governmental and societal levels are necessary to deal with these challenges
to population health. The Jordanian government and its people, however, face two significant
obstacles if they are to deal with these problems. One is that family planning is still a relatively
new concept in the Arab world. The second is that, in Jordan, any attempt to implement family
planning must consider the context of gender constructions and family-centered social
networks. The identity, if not the value, of many Arab women is often shaped by their ability to
reproduce. An acceptance of the limiting and spacing of children through contraception would
therefore signify notable changes in cultural values. It may, in some cases, signify a movement
away from the primacy of childbearing toward attitudes of population health, economic
sustainability, and social responsibility. Thus, an important question for the Hashemite
1
Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key
Findings, Calverton, MD, USA: ORC Macro, 2003.
2
Setty-Venugopal, V. and U.D. Upadhyay, Birth Spacing: Three to Five Saves Lives, Population Reports, Series
L, 13: 2. Baltimore: John Hopkins Bloomberg School of Public Health.
Kingdom remains whether or not the potential for such positive change in women’s family
planning practices exists in Jordan. In an attempt to answer to this question, Jordan’s Ministry
of Health, with the cooperation of the Primary Health Care Initiatives (PHCI) Project, has
implemented an extensive campaign aimed at increasing birth spacing awareness and societal
family planning acceptance.
Planning for the current national campaign began in 2001 with funding from the United
States Agency for International Development (USAID).3 The campaign, which features a
cartoon child named “Sahhii”4 in a real world environment giving advice about various
reproductive health issues, is being implemented in three distinct phases. Given the culturally
acceptable time after marriage in which contraceptive knowledge may be disseminated to
women, each phase primarily targets pregnant women and newly married couples. The first
phase began in January of 2003, promoting the benefits of a healthy mother and child during
pregnancy as well as informing women of the benefits of breastfeeding. The conclusion of this
first phase in August of 2004 coincided with sixteen focus group discussions to evaluate its
effectiveness. Used to develop the second phase of the campaign, the focus group suggestions
allowed program planners to modify the Sahhii character and address participant concerns. The
second phase, set to run through the end of December 2004,5 focuses on the benefits of birth
spacing and informs women about the availability of various contraceptive methods. Campaign
messaging consists of appeals to values such as child health and nutrition, maternal health, and
the general well-being of family, in order to promote spacing between children of at least two
to three years. Its success would mean widespread knowledge and acceptance of spacing
3
4
Hamzeh, M. Interview, 11-24-2004, Ministry of Health Department of Health Education, Amman
Arabic word for “healthy”
methods necessary for fewer mistimed or unwanted pregnancies, a decline in infant mortality
and an increase in maternal health. To reach women in all sectors of society, the campaign has
utilized a full range of media outlets including television advertising, radio messaging,
billboard signage, printed handouts, and documentary film, each bearing the consistent
message encouraging two to three years spacing between children. Commercials air on three
government television channels and FM and AM government radio stations. Eight television
commercials are aired daily while fourteen messages are played on the radio each day. A
sample of 200 women tested the commercials before they were aired.6
The Ministry of Health’s birth spacing campaign takes place at a time when traditional
gender roles and current trends in Jordan’s population growth rate seem to suggest that the
usage of birth spacing methods is quite low and attitudes toward contraception primarily
negative. Through personal interviews with several Amman-based healthcare providers and a
random sample of women taken from various areas of Amman, it is expected that the opposite
will be proved true. The resulting data will likely find differing attitudes toward various
methods of birth spacing and a variation in attitudes and levels of knowledge between age
groups as well as marital status. Yet considering Jordan’s current socio-economic situation,
women’s attitudes towards family planning should be quite positive overall, and the influence
of the Ministry of Health’s awareness campaign promising.
As such, the present study focuses on levels of knowledge, contraceptive practices and
sources of information as indicators of family planning campaign success. It is ultimately my
intention to examine the cultural constraints, which determine the effectiveness of such
5
The third and final phase of the campaign will begin in December of 2004, focusing on knowledge and
utilization of the Ministry’s health centers in an effort to improve contraceptive and information access. The third
phase will build on the messages created during the previous two segments of the campaign.
6
Hamzeh, M. Interview, 11-24-2004, Ministry of Health Department of Health Education, Amman
campaigns in Jordan. In the process, however, I hope to evaluate the impact of the current
reproductive health campaign by attempting to understand the attitudes Jordanian women hold
at the present time towards family planning and birth spacing. Policy makers and educators
face numerous barriers in the distribution of family planning information, many of which are
cultural or social in nature. These obstacles make it difficult to predict the success of family
planning promotion programs in influencing women’s current attitudes toward contraception.
A better understanding of the underlying cultural or social barriers may allow program
planners to capitalize on positive social forces, using the available social norms to construct
more effective campaign messaging.
Rationale
Family planning issues in Arab societies are often subject to strong underlying social
factors that demand careful understanding before an effective awareness campaign is created.
Several studies completed within the last five years address reproductive health needs of
women across Jordan in an attempt to do so. These studies have stressed the need to utilize
birth spacing and contraceptive use as part of a comprehensive plan to reduce rapid population
growth and improve population health. In addition to regular demographic health surveys
completed every five years in the Kingdom, a surprising amount of literature exists on the
factors influencing family planning decisions in Jordan. While the most substantial studies
were completed in Jordan over three years ago, they provide us with the conditions against
which to base the findings of the current study.
Conducted under the premise that the private or subconscious attitudes of women
toward contraceptives will determine their willingness to adopt a family planning method,7 the
7
Bernhart, M. and N. Khoury, Perceptions of Contraceptives Among Jordanian Women, CMS/Jordan and Market
Research Organization: 2001
first study reveals several important socially-shaped perceptions toward three well-known
methods of contraception. Researchers Michael Bernhart from Commercial Marketing
Strategies (CMS/Jordan) and Nadine Khoury of the Market Research Organization employed a
projective technique in which the underlying feelings and beliefs of Jordanian women toward
three contraceptive methods were explored by asking them to interpret fictitious medical
records of other women. The three methods assessed in the study were voluntary surgical
contraception (VSC), the rhythm method, and the intrauterine device (IUD). Each method
yielded a very different reaction from participants, according to Bernhart and Khoury.
First, compared to other methods, VSC—also known as surgical sterilization—received
the most negative reactions from the women.8 The majority viewed the woman utilizing the
VSC method as uneducated and unaware of the consequences of her actions. They also
perceived this woman to be indifferent to her husband, living in poverty, and incapable of
caring properly for her family. This unfortunately seems to suggest a social perception that a
woman adopting a permanent method of contraception cannot handle her primary
responsibility of childrearing.
The second method tested in this study, the rhythm or calendar method, also produced
negative reactions among the women, though to a lesser extent than that of the VSC patient.9
The fictitious woman choosing to use only the rhythm method was perceived as a decent
person, though old-fashioned and traditional. While she refused to change her life to adopt a
modern method, she was also perceived as willing to take risks with an unreliable method. Her
husband, interestingly, was described as less concerned with the care of his family than would
a husband whose wife had used a modern, more effective method. Previously, a lack of
8
9
Bernhart and Khoury, 23
Bernhart and Khoury, 2.
awareness and acceptance of contraceptive methods has been widely believed to be a socially
constructed adherence to tradition, often with religious implications.10 Yet from data collected
during their study, Bernhart and Khoury conclude that “A traditional method is not used out of
attachment to tradition, but at least in part out of doubts about side effects…associated with
modern methods of contraception. Tradition is not, in itself, valued when it comes to
contraception.”11
Finally, in contrast to the prior two methods, participants asked to evaluate the woman
using the IUD responded with far more positive than negative perceptions. She was described
as a modern woman, who cared for her family and had a good relationship with her husband.12
From this method, one general implication that may be drawn is the strong link between
modern forms of contraception and care for the family, especially the family’s standard of
living.13 Ultimately, the study found that to limit or space births is viewed as a responsible act
that protects the welfare of family members.
A second study entitled, “The Contraceptive-Adoption Process in Jordan,” conducted in
2001 by Commercial Marketing Strategies Jordan (CMS/Jordan), in collaboration with the
Jordan Center for Social Research, analyzed the process used by Jordanian women when
adopting a modern method of contraception.14 As part of the study, 155 married women who
had adopted a modern method of contraception in the last 18 months were surveyed. The study
examined some of the elements of the contraception-adoption process for Jordanian women,
ranging from the women’s satisfaction levels with different contraceptive methods to their
10
Underwood, C. “Islamic Precepts and Family Planning: The Perceptions of Jordanian Religious Leaders and
Their Constituents,” International Family Planning Perspectives, 2000, 26(3).
11
Bernhart and Khoury, 3.
12
Bernhart and Khoury, 3.
13
Bernhart and Khoury, 23.
confidantes and counselors in the decision to use them. According to the study, women most
frequently sought the advice of physicians when contemplating a family planning method.
Alternatively, a woman’s husband, while influential in her decision to begin or discontinue
contraception, was much less so when it came to selecting a contraceptive method.15
One major finding of the study dealt with contraception discontinuation. Michael
Bernhart and Mousa Shteiwi, researchers for CMS/Jordan and the Jordan Center for Social
Research, respectively, found that “very few women abandoned fertility regulation
altogether.”16 Instead, women dissatisfied with modern methods either switched to a different
modern form of contraception or decided to use a less reliable form of traditional
contraception. While the results of the current study show otherwise, the CMS/Jordan study
also attempts to prove that the majority of women using traditional methods of contraception
were not dissatisfied former users of modern contraception, dismissing the role of side-effects
in a woman’s perceptions of hormonal methods. The majority of subjects in the CMS/Jordan
study did readopt a method of contraception after discontinuing usage of the first. However,
this study does not address the underlying factors that may lead a woman to discontinue
contraception in the first place. It is such broader societal barriers that most greatly undermine
the possibility of adopting family planning methods, limiting the effectiveness of contraceptive
counseling and weakening a woman’s social access to reproductive healthcare.
The government’s current campaign to raise awareness about birth spacing and
reproductive health stems from the outcome of similar studies conducted by various marketing
firms throughout the Kingdom. Outreach campaigns now include television and radio
14
Bernhart, M. and M. Shteiwi, The Contraception-Adoption Process in Jordan, CMS Jordan and Jordan Center
for Social Research: 2001.
15
Bernhart and Shteiwi, 3.
16
Bernhart and Shteiwi, 14.
commercials as well as door-to-door grassroots work, the training of medical providers, and
counseling services in hospitals and clinics. It is crucial to assess the effectiveness of
awareness campaigns in delivering information to women in Jordanian society if resources are
to be used most effectively in creating positive social change in the future.
Methodology
Reproductive health decisions impact the lives of women across all parts of Jordan.
For purposes of narrowing the focus of this study, I will concentrate primarily on women living
in the capital city of Amman. As I have chosen to limit my analysis to women and healthcare
providers within the city, the results of my research will be applicable to this urban population
only. Rural populations may display different levels of social conservatism as well as more
limited access to information and birth spacing methods. Modern communication methods
used by the birth spacing promotion campaign such as television advertisements are often
inaccessible to rural populations living in small villages and Bedouin communities.
Recognizing that an urban study would still need to account for the situations and perceptions
of a very diverse group of women, my research sample is comprised of twenty-two women of
various ages and socio-economic levels residing throughout the city. As the sample is limited,
it is not my intention to claim that the findings of this study are entirely representative of the
larger population of women in Amman, only that the experiences and beliefs expressed by
these women exist and contribute to the broader understanding of women’s reproductive health
in Jordan. In this context, a randomly selected, diverse sample of women provides the most
meaningful insight into the range of attitudes and perceptions Jordanian women hold toward
family planning. Conducting research across various social groups and geographic areas also
allows for an evaluation of the scope of the current family planning and birth spacing
awareness campaign in the Kingdom. Participants ranged in age from 19 to 53, with an average
age of 30.6 years. Marital status was similarly varied. Just under one-third (31.8%) of the
women interviewed were either unmarried or engaged. Nearly two-thirds (63.6%) of the
subjects, were married, while one woman had obtained a divorce. Reflecting the societal reality
present in Amman, the majority of participants were Muslim (of which, roughly three-quarters
wore the hijab), with only one participant identifying herself as Greek Orthodox Christian.
Fifty percent of all women interviewed were employed outside the home. Of the remaining
half, 13.6% described themselves as full-time students, while 36.4% were unemployed or
worked as homemakers.17
I chose to draw subjects from several different areas of Amman, once again to collect a
broad range of values and perceptions. Participants were randomly selected and approached for
interviews in Abdoun, Jabbal Hussein, Jabal Amman, Downtown and areas of East Amman, as
well as the area surrounding Jordan University. These areas were selected for their potential to
represent the extent to which differences in economic levels may influence current practices
and perceptions.
I began by creating a list of questions that would be asked of each woman.18 Many of
the questions served to elicit descriptions of the women’s practices as indicators of their
attitudes toward contraception and family planning. Others more directly asked the women to
describe their comfort with certain practices and to explain their perceptions of the current
birth spacing awareness campaign. Due to the sensitive nature of the subject, I felt it necessary
to hire a translator for the areas in which little English was spoken. The translator was shown a
copy of the questionnaire and made aware of her obligation to maintain the confidentiality of
17
18
See Table 1 for all demographic information on subjects.
See Appendix A.
participant responses. Translation was utilized in Jabal Hussein, Downtown and East Amman.
As each subject was approached, she was given an explanation of the study and the concept of
confidentiality was explained. The conversation did not begin without documentation,
information and verbal consent. To protect the identity of each woman, all were given a subject
code prior to the discussion of any information. The code served as the only identification
information recorded with notes from each interview.
The sensitive nature of family planning in Muslim countries necessitates the use of
culturally-appropriate terminology when discussing the issue. Sexuality in Jordan is rarely
discussed openly, especially with strangers. Therefore, in order to effectively communicate
with my subjects, applicable reproductive health terminology was translated into Arabic and
evaluated for its cultural appropriateness before the interviewing began.19 Understanding the
values present in this society helps to take a more delicate approach to an already sensitive
subject. Terms such as “family planning,” “birth spacing” and “reproductive health” were used
in place of the inappropriate term, “contraception” (which literally translates to “prevent
births” and may be viewed as disrespectful toward Arab cultural values of family and children)
or potentially offensive terms such as “sexual health.” These considerations were made to
avoid making subjects uncomfortable in any way during the interview. The cultural
implications embedded in language alone highlight the challenges facing those in charge of
marketing efforts for the Kingdom’s family planning campaign.
To supplement the series of personal interviews conducted throughout the city, several
professionals were interviewed—both doctors and pharmacists—who were responsible for the
direct provision of both contraception and reproductive healthcare counseling. These
19
See Appendix B for English translation of terms used during each interview.
individuals provided me with further insight into the social constructs shaping their role in the
family planning process and will be discussed in further detail shortly. Finally, it was necessary
to interview a representative from the Ministry of Health responsible for the planning and
implementation of the national reproductive health campaign.
Findings
Personal conversations with each of the twenty-two women revealed several important
themes, which may be taken either in context or in contrast to the findings of more quantitative
studies. Regular demographic health surveys can assess the practices of women as indicators of
family planning acceptance, and thus use statistical data to evaluate the success of family
planning campaigns. Yet, statistics alone cannot fully explain concepts as complex and socially
driven as contraception and family planning. Attitudes may evolve before any change is seen in
practice if action is impeded by social restrictions, just as practices may change without the
development of new attitudes. It is therefore essential to understand the cultural factors guiding
this change. The attitudes of each woman, articulated during the interviews, provide valuable
insight into the complexity of their perceptions, as well as clues to the most effective modes of
reaching Jordanian women with reproductive health information.
While this was not designed as a statistical or quantitative study, I have found it
interesting to note some of the behavioral trends before attempting to analyze the more
qualitative findings of the project. First, when taken collectively, the fertility rate for married
women surveyed was 3.120—just under the national rate of 3.5 reported by the 2002 Population
and Family Health Survey.21 The wanted fertility rate, or the number of children desired by the
women (used to determine the rate of unplanned or unwanted pregnancies), was 2.9 for the
20
See Table 1.
total sample of women interviewed and 2.5 when considering only the wanted fertility rate of
married women.22 At the national level, this rate among married women is 2.6, while the rate
for women living in urban areas and in the central region of Jordan (both of which include
Amman) is 2.5.23 This indicates that the present sample interviewed, though seemingly
representative of the city’s population as a whole when considering similar fertility rates, may
be less demonstrative of the gap between actual and desired pregnancies when compared to the
findings of the national survey.
One of the most promising results of this study was the 100% familiarity with the
concepts of birth spacing and family planning, even among those unfamiliar with specific
contraceptive methods. Only slightly less widespread were the levels of awareness for the
Ministry of Health’s “Sahhii” campaign, with eighty-five percent of all women interviewed
familiar with Sahhii, the central character in each of the promotional commercials. Only two
women were unfamiliar with the Ministry’s new marketing strategy. These women were
among the youngest in comparison to the majority of participants. They had just finished
school, had not attended the University, and claimed to watch very little television. These
women were aware of family planning and birth spacing, but had learned about the concepts
from an alternative source.
Reasons for supporting family planning and the spacing of births were varied, but
included maternal and child health, financial stability and family responsibilities as expressed
through Islam. As one woman explained, “I told my husband I needed four years to rest after
my first son was born. Then my son needed an extra year on his own, before another child, and
21
Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key
Findings, Calverton, Maryland, USA: ORC Macro, 2003.
22
See Table 1.
my husband did not object because it was my decision.” Echoing an emerging awareness of the
development and regenerative benefits of waiting, a second adds, “We must have two years,
baby and me.” Virtually all women expressed plans to wait between pregnancies to give each
child time to grow. Yet, while each woman quoted two, three, or even five year intervals
between births as ideal for child and maternal health, this knowledge was far from practiced.
Forty-percent of married women interviewed expressed prior experience with an unplanned
pregnancy—either mistimed or unwanted.24 In one-third of these cases, women revealed that
their husbands had objected to the timing of the pregnancy, suggesting the important role of
male involvement in delaying and spacing births.
While this study found that attitudes toward spacing are for the most part very
optimistic, it also shows the many ways in which social factors prohibit women from achieving
their desired intervals. One 32 year old woman nursed her ninth child as I interviewed her in
her home. Her husband had told her that it would be better to have kids one after another, so
that she could “rest when she was done.” While some women cited their husband’s desire to
have more children and their own desire to allow for natural processes as reasons for birth
intervals of less than two years, the most surprising data revealed that gender preference was
one of the most influential factors driving the decision to space children. The average birth
interval for women whose first born child was female was 1.7 years, while couples who first
gave birth to a male infant waited an average of 2.7 years to have another child.25 These data
are consistent with what I have learned from speaking with the individual women: if a female
child is born first, a woman will be less likely to wait the recommended two years before trying
23
Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key
Findings, Calverton, Maryland, USA: ORC Macro, 2003.
24
Revealed through personal interviews with each woman. See questionnaire used during interviews (Appendix
A).
to become pregnant again, in hopes of having a boy. Every woman interviewed, married and
single, acknowledged the desire and ever-present societal expectation to have a male child.
With one exception,26 male was the gender of the last child in all families with multiple
children, suggesting that a woman will have children until she produces a male or, if possible,
more males than females.
Just as gender preference may play a significant role in determining birth intervals, a
woman’s decision to breastfeed her child seems to correlate with the spacing of children as
well. Several specialists in the field of women’s reproductive health have suggested a
connection between fertility and the duration of breastfeeding, particularly as an indicator of
birth intervals.27 That is, women who breastfeed their children for short periods of time or not
at all tend to have shorter intervals between births. The current study reveals the median
duration of breastfeeding for my sample is just less than 10 months (9.9 months);28 alarming
considering the median duration of breastfeeding is 12.7 months for the population living in the
Central Region of Jordan and 13.0 months for the population living in urban communities.29 In
Jordan, breastfeeding is widely understood—somewhat falsely—to act as a reliable form of
contraception.30 While lactation may indeed make pregnancy less likely, the sole use of this
method may result in unplanned pregnancies which paradoxically will lead to shorter periods
of breastfeeding. Several participants in this study, in fact, admitted to an unplanned pregnancy
that had occurred while breastfeeding without the use of modern contraception. These women
admitted to breastfeeding for a maximum of six months, often less than three depending on
25
See Table 1. Birth intervals calculated as average number of years between first and second child.
In the only family where this did not hold true, the woman had had four daughters in an attempt to have a son.
The mother was nearing menopause and had given up on prospects of becoming pregnant with a boy.
27
Setty-Venugopal and Upadhyay, 17.
28
See Table 1 for individual breastfeeding intervals.
26
when pregnancy occurred. Conversely, women who choose to breastfeed for only a short
period of time will not benefit from lactation’s contraceptive effect and are more likely to
become pregnant if no other method of contraception is employed. Besides the obvious health
benefits to the child, this is one reason many experts encourage women to breastfeed for the
full two years and consider a second form of contraception if they do not wish to become
pregnant. Dr. Amin Nasser, Senior Consultant at Red Crescent Hospital in East Amman,
explains that each mother must be aware of the failure rates of breastfeeding as a form of
contraception. He expresses his concern saying, “The longer a woman breastfeeds, the more
likely it is she will become pregnant. If she commences her period during lactation she must
use another method and take care not to become pregnant.”31
In addition to the health-based motivation for breastfeeding a full two years, my
interviews have identified a very powerful source of persuasion in Islam. Chapter two, verse
two-hundred thirty-three of the Qur’an calls Muslim women to breastfeed their children for
two years.32 “The baby must take milk from a woman’s body for two years,” one woman
explained in reference to this holy edict.33 Faith-based recognition of the relationship between
breastfeeding and birth spacing on the part of several participants, married and unmarried,
provided them with an authoritative reason to space their past—or future—pregnancies. Islam
may even inspire women to utilize modern methods of contraception while breastfeeding in
order to ensure the full two-year lactation period prescribed by the Prophet Mohammed.
29
Department of Statistics [Jordan] and ORC Macro, Jordan Population and Family Health Survey 2002: Key
Findings, Calverton, Maryland, USA: ORC Macro, 2003.
30
Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman
31
Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman
32
The Noble Qur’an, University of Southern California Muslim Student Association, <http://www.usc.edu/
dept/MSA/quran/>
33
See Table 1.
For each of the aforementioned reasons, breastfeeding holds great potential to be one of
the most effective culturally appropriate methods of prolonging birth intervals. This may also
be one of the reasons the Ministry of Health chose to emphasize breastfeeding during the first
phase of the campaign, prior to the promotion of birth spacing and family planning. By
acknowledging the importance of breastfeeding each child for two years, women may seek
family planning methods to prevent unplanned pregnancies during this period.
It is important, of course, to acknowledge that underlying perceptions about
contraceptives may undermine the effectiveness of a campaign entirely contingent on
breastfeeding promotion. While all married women interviewed for this study were familiar
with some form of contraception,34 perceptions were surprisingly negative for modern methods
and varied among the traditional methods employed. Of the married women interviewed as
part of this study, just under three-fourths (73%) had used a form of contraception at some
point.35 Sixty percent had used a modern form of contraception. Of these women, only onethird were still using that method,36 while another third had discontinued use due to pregnancy
or to become pregnant. One woman had reached menopause and the remainder felt more
comfortable with traditional methods such as the rhythm method or withdrawal. Very few
women interviewed had experience with more than one modern method.
The reasons given for either discontinuation or non-usage were extremely varied,
though each response merits careful consideration of its possible cultural implications. The
most common reasons for stopping a modern method of contraception were related to the side
effects and the health consequences of modern contraception. Many women turned to more
34
Several married women described their knowledge of contraceptives as limited, or were only familiar with one
or two modern methods.
35
See Table 3.
traditional methods after discontinuation of either the Pill or the IUD for this reason. Several
felt uncomfortable with the hormones in oral contraceptives, but were completely satisfied with
condoms. Other motives for non-usage of reliable forms of contraception included infertility
concerns, age (if the woman felt she had little childbearing time left at the time of marriage), a
desire to let the number and spacing of children be determined by the will of God or nature,
and a stated lack of information.37
Provider Perceptions: Insight from Doctors and Pharmacists
As the primary providers of family planning counseling and services, doctors and
pharmacists have much insight to offer a study on the underlying cultural factors contributing
to a woman’s attitudes towards family planning and birth spacing. For the purposes of this
study, the perceptions of doctors and pharmacists interviewed will be used strictly to illustrate
their own rationale for types and methods of counseling services provided and the women’s
observable behavior, rather than as an attempt to make claims about the attitudes, perceptions
and driving forces behind decisions made by the women they serve.38
Dr. Jeries Salaytah, a private obstetrician/gynecologist in Amman, sees one to two
women daily about their contraceptive and family planning needs.39 The majority of his
patients are between the ages of 30 and 35, though he does see a small number of women in
their twenties. This older age group may be explained mainly by a social expectation of
pregnancy immediately following marriage. The younger women—those either engaged or
newly married—will not likely seek contraceptive guidance from a physician until after their
first pregnancy. Dr. Nasser, who sees between 700-800 women per year at the Ministry of
36
Twenty-percent of all married women surveyed were currently using a modern method of contraception as
compared to the urban rate of 42.6% according to the 2002 Population & Family Health Survey.
37
See Table 3.
Health’s Comprehensive Post-Partum Center (CPP), expands on this concept, estimating that
“not more than five to ten percent [of engaged women] will go for contraceptive advice before
marriage…Once married, it’s rare for a woman to consult a physician about contraception
because she’s trying to become pregnant.”40 In fact, he says many women come only if they do
not become pregnant within the first few months of marriage. Infertility, Dr. Nasser
emphasizes, creates a fear in many young women perpetuated by an understood procreationdriven and defined worth in the eyes of “nagging mother-in-laws.”
The counseling a woman receives determines, in part, her perception of various
methods, while her current situation will determine which method works for her family
planning goals at that point in time. A woman may strongly support the concept of family
planning, but if a lack of comprehensive information has instilled in her a fear of modern
methods, she has been robbed of the capacity to plan pregnancies and control the spacing of
her children. Both doctors had much to say on the topic of contraception counseling and
usage, particularly in relation to their place in the dialogue. When asked to describe his role in
advising women about various contraceptive methods, Dr. Nasser explains:
In proper counseling, you don’t tell a patient what to take—you let her decide. You
have to give attention to what the patient wants; this is most important. Each woman
has her own life, knows what will work for her and what she’ll follow through on. It’s
the doctor’s role to give the positives and negatives of her choice.41
Listening to a woman and attempting to apply individual circumstances to the provision of care
are important steps in a positive direction, though many cultural tenets still affect the provision
of counseling. This may be because an understanding of the needs and desires of the women
38
It should be noted that all currently-practicing doctors interviewed during this study were male, while all
pharmacists were female.
39
Salaytah, J., MD, Ob-Gyn. Interview, 11-22-2004, private clinic, Amman
40
Nasser, A., MD, Ob-Gyn. Interview, 11-30-2004, Al-Amal Hospital, Amman
41
Nasser, A., MD, Ob-Gyn. Interview, 11-30-2004, Al-Amal Hospital, Amman
served is inevitably influenced by a doctor’s underlying cultural preconceptions. Dr. Salaytah
explained to me the preference of young, married woman toward oral contraception as opposed
to the IUD as he understood their motivations behind this preference. “I try not to prescribe the
IUD for women without children, or male children in particular as there is a greater risk of PID
with the IUD,” Dr. Salaytah explains.42 Pelvic inflammatory disease, or PID, is a leading cause
of female infertility, which in this context clearly exemplifies a perpetuation of gender
preference norms in Arab society. Dr. Nasser clarified for me the fact that advice on methods
of contraception depends on a variety of factors—culture, a woman’s situation, the number of
children she has, and her age, among others.
The previously discussed Contraception-Adoption study completed by CMS/Jordan and
researchers from the Jordan Center for Social Research found that of women seeking advice on
method selection, 72% sought advice from a physician.43 Yet this same study acknowledged
that the most personal information may come instead from pharmacists, who have more time to
devote to each woman and have comparable knowledge levels. One pharmacist I interviewed
acknowledged the more significant role of doctors in contraceptive counseling. “Here they
depend more on doctors than they do on pharmacists. What he advises, she takes,” she said, “I
can educate people, but I need people to listen.”44 She feels the pharmacy is the best place to
dispense contraception, commenting that people do need to be more educated about pills,
condoms and all kinds of contraception. “People in Jordan like children—3, 4, 5—even if
there’s no money.” The ability of many doctors to provide quality counseling was another
issue. Continuing she said, “Some doctors here—they need education. Not all of them are
educating women about family planning. Some of them are doing a good job, but some work
42
43
Salaytah, J., MD, Ob-Gyn. Interview, 11-22-2004, private clinic, Amman
Bernhart, and Shteiwi, 3.
only for the money—they have no time to talk to the patient, no time to educate the patient.”
Dana Diab, a second pharmacist in Amman, though her place of employment is located in a
considerably more affluent area of the city, expanded on the role she plays as a primary source
of contraceptive information for many women. “Every other woman comes in asking for
contraceptives,” Diab says, “Women cannot live without them.”45 Her female clientele are all
married, and the majority fall between the ages of 25 and 35, she reports. Birth control pills are
the most widely distributed form in the pharmacy. In Jordan, contraceptive pills (and IUDs for
that matter, though these must be inserted by a physician) may be purchased over-the-counter
(OTC) without a doctor’s prescription. Diab estimates that between 30% to 50% of the women
she assists regularly come to the pharmacy without seeing a doctor. This means that without
counseling on the part of the pharmacist, a large percentage of the women currently using any
of the available OTC family planning methods could be doing so while lacking adequate
information to determine the best method for them and their families.
Women & Their Stories: Case Studies from the Field
(* denotes names have been changed to protect the identity of the women)
While statistical findings and professional experience have provided a wealth of insight
into the cultural factors influencing women’s family planning decisions and the campaigns that
attempt to shape them, the truly meaningful information has come in the form of personal
stories disclosed by the women themselves. The following stories have been provided in an
effort to convey the effect social constraints have had on each woman’s personal experiences
and beliefs, despite a growing social consciousness surrounding birth spacing and reproductive
44
45
Shoubash, S., Interview, 11-28-2004, Meral Pharmacy, Amman
Diab, D., 11-22-2004, Abdoun Pharmacy, Amman
health. The name of each woman has been changed to protect her identity and the integrity of
her story.
Leila*
Married just 3 months ago, Leila is a 28 year old Muslim woman facing her first
pregnancy. I met Leila one morning at the office where she works as a secretary. Leila has only
recently begun to see a doctor—she had no need before the wedding. In the two visits she had
with her doctor before she became pregnant, family planning was never mentioned. Now, Leila
faces the prospect of quitting her job to care for a child that came too early. She had wanted to
wait longer, though she lacked the knowledge or means to plan. “Doctors don’t usually discuss
family planning with a woman until the first child is born,” says Dr. Nasser, who offers family
planning counseling to every patient after delivery, “Contraception is discussed postpartum…you talk to them during or after the pregnancy.”46 While still young, Leila is older
than many Jordanian women preparing for their first pregnancy. Health professionals like Dr.
Nasser often hesitate to initiate the dialogue with women in this age group for fear of offending
a potentially barren woman. Unfortunately, remaining sensitive to fertility concerns and the
value placed on children in this culture often means mistimed pregnancies for recently married
women like Leila.
Doctors are not the only ones responsible for a lack of information among newlyweds
though they are, in fact, the most frequent source of family planning information;47 society as a
whole may be to blame. Family planning is a relatively new concept in Jordan, and is even
newer to Leila, who, like so many other young Arab women, could not discuss family planning
or contraception before marriage. In Jordan and most Arab countries, concerns about women’s
46
47
Nasser, A., MD, Interview, 11-30-2004, Al-Amal Hospital, Amman
Bernhart and Shteiwi, 2.
purity before marriage overshadows the importance of reproductive health information. From
my conversation with Leila, I was given the impression that she, herself, had not wanted to
know about contraception before her wedding night. From this young woman—and many other
respondents both single and recently married—it has become very apparent that people will
begin to talk if a girl knows too much about contraception before she is married.
Now that Leila is aware of birth spacing, she intends to wait two years before the next
child. “There should be two years between,” she said to me, “That’s why I need to start
thinking hard now about contraception.” She knows very little—only about traditional forms
such as the rhythm method, though she is aware of their high failure rate. After three months of
pregnancy, Leila still has not broached the topic of family planning with her husband, “After
the first baby, maybe,” she says, “I don’t know enough yet. I will go to the doctor to see any
method she advises.” Still unsure of available methods as she looks ahead to her first child,
Leila has many options but a critical period in which to learn about them.
Salma*
I met Salma in her home in East Amman, where she lives with her husband and four
daughters—ages 19, 20, 21, and 23. Now age 45, Salma, who works part time with the
Productive Women’s Institute in Jordan, has quite a bit of experience behind her. Married at
age 19, she left her family to live with her husband and start a family. She gave birth to a
daughter three years later. Less than a year after her first pregnancy she became pregnant again
in hopes of bearing a son. Even now, within years of menopause and as her daughters reach
marriageable age, her husband’s family still pushes her to continue childbearing. “In this
culture, it’s important to bring a boy,” she said, “They told me I needed a boy and should keep
having children, but I didn’t listen.” Her husband supported her choice. Four children had
taken their toll on her body—and the family’s finances. It was time to stop.
Through experience, Salma now recognizes the value of family planning. Her last two
pregnancies were unplanned and all but the last two occurred less than a year apart. Her rapid
pregnancies had prevented her from breastfeeding for two years, though she explained the
necessity to do so, based on Qur’anic instruction. Unaware of the benefits of birth spacing
before her children were born, Salma expressed her support for family planning now. “We
must do more to take care of [our children],” she confided in me, “All the girls came at the
same time. If you want [your] kids to have a good education, to feed them well, four is
difficult. If I’d known it would be this difficult, I would have only brought two.” Salma’s
contraceptive history reflects the lack of reproductive health information she received early in
her marriage. She had relied on the counting method, alone, until her last daughter was born. It
was only at this point, after four children, that her doctor began to advise her on modern
methods of contraception. She opted for oral contraceptives over the IUD, using the pills for
nearly ten years before side-effects led her to discontinue the method.
Now, Salma’s daughter is engaged, and she looks ahead to the time when her daughter
will be making family planning decisions of her own. She has been given the opportunity to
provide her daughter with the valuable reproductive health information that she lacked at the
same age. Salma’s personal experience has created valuable opportunities for the next
generation. Unlike many girls her age, her daughter is aware of oral contraception, though her
knowledge of other methods is extremely limited. Although the discussion of contraceptive
methods with her fiancé is not allowed before marriage, Salma’s family has decided to sit
down with the engaged couple, before the wedding, to discuss family planning issues such as
when and how many children the couple will have.48
48
Note the continued parental role in family planning decisions, even among more progressive families where
reproductive health concerns are openly discussed.
Fatma*
I sat down with Fatma in the dress shop where she works. A single, though nearly
engaged Muslim woman in her mid-thirties, Fatma had a lot to say about the current family
planning situation in Amman. Born and educated in Kuwait, Fatma knew about family
planning and reproductive health, though very little about contraceptive methods. “In this
country,” she told me, “it’s a shame to talk about family planning before marriage.” Though
she has discussed future children with her fiancé, discussion of methods, as for all unmarried
women, is forbidden. Even with her doctor, she cannot discuss the issue. She plans to sit down
and discuss methods with her husband and doctor once she is married. Because of her age,
Fatma insists, “there is a different look to this subject [of family planning].” She hopes to have
four kids someday, and acknowledges that if she plans to space her children two years apart “as
Prophet Mohammed instructed”, she will have to hope for twins—twice.
Fatma learned much of what she knows from her mother. “We must teach our mothers
to talk to her kids,” said Fatma, “There is a bad thing happening in the new generation—the
girls talk amongst themselves and don’t ask questions [of their mothers].” Fatma proceeded to
tell me the story of a girl who had asked her if a kiss could cause pregnancy. That kind of
ignorance astonished Fatma, though she herself lived within the same information-deprived,
social constraints as the majority of single Jordanian women. Fatma’s own mother had many
problems with oral contraception and the IUD. Because of this, Fatma was skeptical of modern
methods, instead favoring traditional calendar methods. “All the artificial ways have sideeffects,” she added matter-of-factly, though she assured me that she would consider her options
according to the doctor’s advice once she marries.
Conclusions
In general, the attitudes toward family planning revealed in this study have been very
positive, with awareness of birth spacing, family planning, and the Sahhii campaign nearly
universal within the total sample of women. The Ministry of Health’s Sahhii campaign has
been very successful in creating messages appealing to the women I interviewed, as well as
their husbands and even their children. By capitalizing on such familial values as maternal and
child health, financial stability and well-being, and the strengths of paternal involvement in the
decision to space births, Sahhii has the potential to reach hundreds of thousands of women
across Jordan.
Unfortunately, appealing to the right social values oftentimes only allows for attitudinal
shifts. It may not produce real changes in practice in the presence of separate cultural barriers
such as those encountered during this study. Results of the present study indicate that although
the campaign has succeeded in informing the public, it may continue to be undermined by such
cultural barriers if not confronted at a broad societal level. While most women agreed with the
concept of birth spacing and family planning, for example, most relied on ineffective,
traditional methods of contraception or did not have access to the information at all. Many
factors, acting beyond the control of women, make it difficult to achieve their family planning
goals. Recognizing the importance of each woman’s attitudes and perceptions in shaping her
current contraceptive and family planning practices is only the first step in effectively reaching
women with reproductive health information. Providing women with the ability to effectively
change their reproductive health practices means considering existing cultural norms and
working within or around complex social and gender constructions.
As explored earlier, the first of these underlying social constraints is the primary role of
women as child bearers in Arab society and the way in which their children serve as the source
of their identity. A woman’s worth lies in her fertility, and as was the experience of many of
the subjects interviewed, a woman is often pressured to continue bearing children beyond her
family planning goals.49 An effective campaign, while not removing this barrier, may appeal
to a woman’s care for her family as motivation for spacing births, if not limiting them in
number.50 A second factor is the role of the extended family or tribe in family planning
decisions such as the number of children a couple will have and how soon. Oftentimes, the
family expects the girl to become pregnant immediately, or to produce a large family.51 Again,
while not removing the barrier, family planning campaigns may appeal to the larger family—a
woman’s mother and mother-in-law primarily—in order to give a woman’s personal decision
to limit or space her pregnancies legitimacy. A third barrier facing women, demonstrated with
empirical evidence from this study, is the value of male children and the effect of such genderpreference on birth spacing. This construction must be confronted at the societal level if its
influence on a woman’s childbearing practices is to be lessened. As seen on a limited scale
within this study, gender preference has the harmful potential to undermine the family planning
awareness campaign if not addressed. A fourth obstacle to overcome is the concept of purity
before marriage as it affects a lack of access to knowledge among single women in Jordan,
many of whom are of marriageable age. This problem can significantly compromise a
woman’s family planning choices and career options by depriving her of knowledge at a time
when she is most vulnerable to unplanned pregnancies. Without information about
contraception before a first pregnancy, women are unable to effectively plan when they first
begin childbearing. Finally, and at a broader level, religion plays an important role in the
development of social constraints beyond the notions of purity mentioned above. Considering
49
50
Setty-Venugopal and Upadhyay, 17.
Bernhart and Khoury, 23.
the effect of Qur’anic reference to breastfeeding periods on birth spacing awareness, it may be
in the best interest of the Ministry of Health to work with Islamic scholars and clerics in the
creation of a more effective reproductive health awareness campaign for Muslim women.
While each of the above social constraints has the power to influence Jordanian
women’s perceptions and practices relating to family planning and birth spacing, they likely do
so in different ways and to different extremes, depending on family situation and each
woman’s status in Amman’s highly gendered and socio-economically divided society. In these
same familial factors, however, lies the potential to create positive change through
reproductive health awareness campaigns at the national level. Of course, it is too early to say
with any certainty what the ultimate effect of the current campaign will be on the family
planning practices of Jordanian women. A movement toward the widespread use of modern
methods of contraception in Jordan has been slow to take hold, and many wait anxiously to see
results. The two year minimum spacing goals promoted by the Ministry of Health, once
practiced, would mean significant improvements in maternal and child health, and would be a
positive step toward achievable family planning goals for all couples. Current practices at the
time of this study do not reflect the full impact of the campaign as of yet, though the level of
awareness and support is promising.
51
Nasser, A., MD, Ob-Gyn, Interview, 11-30-2004, Al-Amal Hospital, Amman
Table 1
Subject
Code
Participant Demographics and Statistical Data
Age
Marital
Status
Age
when
married
Employ.
Status
Religious
Affiliation
Muslim,
no hijab
n/a
4
n/a
male (better
doctors)
1M
10mo
3
no
woman (comf)
n/a
2 to 3
plans to, very important
Muslim,
no hijab
Muslim,
hijab
0
1F + 8
mo.
pregnant
4 (2F,
2M)
1
2
F:8,7; M:5,3
4
yes, 6 mo.
Christian
(G.O.)
2 (1F,
1M)
F:8, M:5
3 (2 is all able
to afford)
yes, 4-5 mo.
Muslim,
no hijab
1M + 6
mo.
pregnant
5
2
yes; 18 mo (1), 2 yr now
male (doesn't
trust fem);
prob. w/ 1st
delivery
U002
21
single
n/a
student
MS01
28
married
27
works
Muslim,
hijab
Muslim,
hijab
Muslim,
no hijab
A002
28
married
student
A003
27
divorced
23
19; div25
A004
39
married
28
either
0
student
works
Doctor Pref.
3 + until boy
n/a
n/a
Breastfeeding
n/a
single
single
Desired #
0
22
23
Age of
Children
plans to, very important for
health (& C.*)
U001
A001
# of
Children
male
female
A005
31
married
24
works
former
teacher,
now
homemaker
A006
37
married
21
works
Muslim,
no hijab
2M
6, 3
2
yes, 8 mo.
male
H001
22
engaged
n/a
finished
studies
Muslim,
no hijab
n/a
n/a
4 (2M, 2F)
plans to breastfeed 6 mo.
female
28
homemaker,
studied in
Baghdad
Muslim,
hijab
3 (2F,
1M)
F:22,21, M:17
3
yes, 6 mo.
female
n/a
n/a
0 + 3 mo
preg.*
n/a
3 or 4
(2F,2M)
2 or 3
(economic
situation now,
diff to have
3+)
n/a
4 (twin M+F)
because of
age
yes, 2 yrs (Islamic
teachings, Qur'an)
Plans to, 2 yrs; "Proph. M/
God says we must have 2
years btwn kids--to my
health, to women…The
baby must take milk from
woman's body for 2
yrs…we must have 2 yrs-baby and me"
1.5
4
"not now"
yes, 1 yr. 3 mo. (got
pregnant); Cited Qur'an-wanted to wait 2 years
M:35,29,26,16;
F:34,31,23
? (done now,
wasn't
something
she thought
of)
H002
53
married
H003
19
single
n/a
works
Muslim,
hijab
H004
28
married*
(3mo.)
28
works
Muslim,
hijab
35
single
(engaged)
works
Muslim,
hijab
n/a
Muslim,
hijab
1F (had
2nd but
lost)
H005
D001
D002
M001
M002
26
53
45
32
n/a
married
married
married
married
homemaker
16
19
18
homemaker
Muslim,
hijab
7 (4M,
3F)
homemaker
Muslim,
hijab
4F
23, 21, 20, 19
homemaker
Muslim,
hijab
9 (5F,
4M)
M:15,9,9, 9
mo.; F:
13,12,6,4,3
4 (if known
this difficult,
only 2)
? (done now,
wasn't
something
she thought
of)
female
yes, 2 youngest-1 yr. 3 mo.;
all others <3 mo.
yes, 1 yr. each (became
pregnant, unable to
breastfeed for 2 years);
Cited Qur'an--2 yrs btwn
children
yes, 1 yr. each
female
female
male,
very close to
home
male,
Jordan
University
(has health
insurance)
male
female
(same for all
kids)
M003
U003
JA01
R001
26
27
30
39
Table 2
married
single
married
remarried
homemaker
Muslim,
hijab
2M +
preg
4, 2
3
yes; 1st - 1 yr., 2nd - 4 mo.
female
works
Muslim,
hijab
n/a
n/a
3
n/a
n/a
25
works
Muslim,
hijab
1F
3
2
?
n/a
27
works,
former civil
engineer in
Baghdad
4 (family
wants more)
1st - 1 mo., 2nd - 1 wk.,
twins - 7 mo. ("I was young
& didn't understand a lot of
things. I wanted my breasts
to stay full.")
n/a
18
n/a
Muslim,
hijab
4
12, 11, 3, 3
Family Planning & Birth Spacing Familiarity
Subject
Code
Knowledge of Family Planning
Knowledge of Birth spacing Concept
U001
yes, very important; loves f.p.--will def. use
yes (2-3 yr)
Source of Knowledge
University
U002
yes, not methods (concept only)
yes
MS01
yes, very important
yes, plans to wait 3 yrs
n/a (biology in school-names only, plans to ask
when married)
University (not discussed before marriage in
home)
A001
yes, very important
yes (2-3 yr); rebuild nutrients, child dev't period
University
A002
yes
yes, 3 years would have been better
Doctor; Pregnancies unplanned, must prevent in
future
A003
yes
yes, 3 yrs: each child has time to grow
Husband was a pharmacist
A004
yes, both children planned
yes, never directly discussed with husband
Doctor
A005
yes, both children planned
yes (3-5 yr apart excellent)
Mother, doctor/clinic
A006
yes
yes
Doctor
H001
yes, not methods (concept only)
yes (2 yrs between); plans to wait btwn children
n/a
H002
yes
yes (2 yrs)
University
H003
yes, not methods (concept only)
yes (2-3 yrs to give time for each child to grow)
Familiar with b.s. from family/community; 10th
grade biology (books)
H004
yes; didn't consider until pregnant (visited dr.
twice before preg., not discussed)
yes, 2 yrs (now needs to think hard about
contraception)
MoH Outreach: Women from MoH came to home
when 25-6; Plans to go to dr., will use any
method dr. advises (except pills-->side effects)
H005
yes (concept only); "In this country, it's a
shame to talk about f.p. before marriage"
(good in one way, bad in another)
yes, plans to space children; b/c of age, will
space only 1-1.5 years (knows 2 is best)
Plans to discuss with husband (has discussed
f.p. & future children, not methods)
D001
yes, recent
yes, plans to wait 2 years before next child
D002
yes, recent
yes (3 years), spacing btwn last two children
TV; husband, told her before marriage (fiance);
doctor has never discussed family planning
Reads about it, knows from media (though
previous commercials not as strong); after 16 yr
old, doctor still didn't advise about f.p. (didn't
know much)
M001
yes, only after children (last 2 unplanned);
f.p. very good--good for the children (send
them to school, feed them)
yes (2 years); unaware before had children
(learned about it 10 years ago)
Doctor advised about pills, IUD; Felt better about
the pills
M002
yes
yes, discusses with husband (says better to
have kids one after another so she can rest
later, tells him it will affect her body but he wants
more kids)
M003
yes, talks about freely with husband
yes, though diff to have children so doesn't need
to plan
Learned about f.p. from dr. after year of marriage
(discussed after 1st preg.) Doctor always talks to
her about f.p./b.s but husband always wants
more children (must do what husband wants)
Learned about f.p. after 1st child born (first time
learned about f.p.); Dr. did not advise on C.
before 2nd child (gave many choices at that
point)
U003
yes, pharmacist
yes (2 years)
First learned about f.p. in University (pharmacy);
now, mainly from TV commercials (starting 2-3
years ago)
JA01
yes, pharmacist
yes (2-3 years)
University; MoH Outreach: 2 home visits--"they
visit all the houses here to educate people"
yes; would have spaced 2 years; thought b/c
fibroid removed after 1st preg, wouldn't get
pregnant
Had to initiate C. conversation with doctor, no
one ever told her--had to ask for contraception;
MoH workers come to Safawi, Special Unit in
Safawi (population 2000)-->women get free C.;
Workshop on R.H. run by charity with help from
UNDP
R001
Table 3
yes, recent
Contraception
Subject
Code
Knowledge of Contraception
Use of Contraception
Explanation/Rationale
U001
yes (pills)
no (plans to, pills)
F.P. very important "because life is difficult for many";
financial ($ is very important), school expenses
U002
no, not discussed before marriage
no
not married
MS01
yes, discussed all options with dr.
yes, condoms
Condoms don't change body, no hormones; affordable
A001
yes, pharmacist
no (plans to, unsure method)
Financially easier (b.s.); Doesn't know body yet (how it will
respond to C.), "hormones are the most important things not
to play with in the body"
A002
yes, limited (methods)
not prior to this pregnancy; plans to use
condoms
Currently studying with 2 small babies; husband upset b/c
preg (financial)
A003
yes
no (no need now, never has)
Doctor recommended IUD, disc. with husband; Unable to use
(health reasons)
A004
yes (IUD, condoms, pills, rhythm);
discuss w/ husb
No modern birth control now, trad./rhythm
method only; pills when 1st married (2 yr)
Decided (w/ husband) that didn't need anything--rhythm of life
A005
yes (IUD, condoms, pills, rhythm)
none before 1st; after 1st, condoms
Pills-->headaches, reaction to IUD, rhythm ineffective; 100%
satisfied with condoms
Never used modern method; Infertility
concerns
Initially withdrawal method (3 yrs); found husband low sperm
count (7 yrs)-->surgery + artificial insemination; 2nd son
naturally; doctor recommended IUD, stayed w/ withdrawal
method (IUD-infertility experience, pills-side effects)
A006
yes
H001
no, not discussed before marriage
no
not married
H002
yes (pills, IUD), though negative
perception
Never modern methods,
rhythm method - yes
"Contraceptives are like a poison in the body" (side effects);
would choose naturally over modern methods
H003
no, methods not discussed before
marriage
no
not married
very limited (pills, rhythm, withdrawal)
no, current pregnancy unplanned; doesn't
know enough yet; will never consider pills,
though rhythm/Islamic method is an
option
Wanted to wait longer before becoming pregnant; "It will
happen by God. Each person has a brain and can think about
the decision for own self" (religious reasoning); Discussed
usage of "wasta," Islamic "connection" method
H004
yes, not discussed; plans to talk to dr.
& husband when married (agreement
important)
no, preferred method for when married-traditional/rhythm method; Decision will
be according to body, circumstances, dr
advice, new knowledge
Mother had many prob. when took pills & IUD ("all the artificial
ways have side effects," but will still consider according to dr.
advice); "With my age, there's a different look to the subject
(of family planning)"; Doctor doesn't discuss the issue at this
time (because not married)
yes (pills, IUD, condoms)
no C. before 1st child, condoms after
daughter born (not always)
Comfortable talking to husband about contraception (he
knows more than her about b.s. & f.p.); Husband didn't want
second pregnancy so soon (mistimed)
yes (pills, IUD)
no C. before 1st two children; IUD used for
4-5 months (didn't wk, caused bleeding);
began taking pills (worked better), used
rest of time (no longer needs)
Bought pills from pharmacy, doctor did not advise to take;
Pregnancy is the will of God; Husband likes many kids--she
told him no more, but he didn't care what she wanted (tired of
becoming pregnant)
M001
yes
No modern methods used before children
born (counting only); Used pills after last
daughter born (used for long period-stopped 10 years ago; currently only
counting
M002
yes (pills, IUD,counting method);
poor information/ exposed to myth
Counting method (has never used a
modern method)
Began to see side effects of pill (nervousness), stopped; "We
must do more to take care of [our children]. All the girls came
at the same time. If you want kids to have a good education,
four is difficult. If I'd known it would be this difficult, I would
have only brought two."
Wants natural way, told doctor didn't want to use any
chemical things (doctor recommended counting); Better for
her not to use contraception--has side effects so does not
believe in them (pills/IUD cause cancer and have negative
effects for body)
M003
yes (IUD, counting, pills, withdrawal)
IUD put in at health center after 2nd child;
plans to use IUD after this pregnancy
Hard for her to become pregnant--first child born after 3 years
(infertility concerns--doctor most likely hesitant to discuss
contraception)
U003
yes (all methods); pharmacist
no
not married
yes (all methods); pharmacist
Took pills but stopped 3 months ago to
become pregnant
Wants to have another child, has waited 3 years
yes
Hadn't used previously, now using IUD
(afraid to forget pill)
Doesn't want more children--she's a professional woman and
already has 4 kids; husband's family pressuring her to have
more (had twins and thinks she can again)
H005
D001
D002
JA01
R001
Table 4
Subject
Code
Additional Data
Sahhii Campaign
Comments/Other
U001
Law student (JU), well-educated; strong preference for male children
U002
yes, commercials
Not comfortable discussing methods- even to think about it before marriage is bad, not something to
talk about before marriage; "of course" would definitely feel comfortable talking to husband about it;
asked if I was married, why I chose to study this
MS01
yes, commercials
Wks w/ HPC; Has discussed F.P. with husband, very supportive; Good idea to talk about in schools
A001
yes
Already considered self old--"[Older women] always prefer not to wait for 1st child"--no need for
contraception when first married; Insistant on purity of unmarried women
A002
yes
Has never used C. before now; Husband supportive of F.P.; Ideal for IUD
A003
unfamiliar
Hormones would effect health if used contraception
A004
yes, commercials
A005
A006
H001
yes, commercials & brocures in
clinics
yes; very popular, 1st campaign
w/ impact; using all media:
billboards, tv, radio; people
identifying with character
unfamiliar with campaign
Lived in Europe for 10 yrs; University distributed condoms in dorms ("useful"); Careful to emphasize
that unable to afford a 3rd child emotionally, financially, and physically
Needed 4 yrs to rest after 1st child, son needed extra year (5); not husbands decision (personal); R.H.
must be taught in schools, teachers need to be more informed, mom/aunt must talk to girl before
marriage
Would like schools to introduce family planning & reproductive health into school curricula
Would not feel comfortable talking to husband about family planning methods and birth spacing; Iraqi
family, mother from Baghdad
H002
H003
H004
yes, commercials; didn't matter
b/c already familiar with b.s.
no (doesn't watch TV)
yes, excellent commercials;
good for educated women and
non-edu. women alike;
Compared to prev. MoH
outreach work
D001
yes, TV commercials; thinks
weird (not used to it in jordan)
but useful; women here not
well-edu. (esp older); shy--hard
for ppl to talk about, sahhiichild-good way to make ppl
comf. talking about it indirectly
yes, TV commercials, very
good; daughter knows them
also
D002
yes, TV commercials--good,
encourages ppl to think about it
H005
M001
M002
yes, TV commercials; doesn't
say 'stop'--emphasizes planning
(not against Islam)
yes, TV commercials: excellent,
encourages people to know
about these things ("in some
villages it doesn't work, they
won't listen")
Discussed family planning with husband (important), same opinion; Very important for schools to
discuss family planning issues
Sister is doctor yet never spoken about family planning (not married yet); Felt good to have family
planning, though appeared not to have thought about it
Awareness in Jordan began ~2yrs ago, family planning is new; Skeptical about effectiveness--sister
used pills and traditional method, still got pregnant rt after 1st child (whatever you use, ult. will of
God); Best place to discuss f.p./r.h. is in women's clinic, not successful in schools; Age 15** suitable
for r.h. education (girls start to ask)
Born, educated in Kuwait--edu. system better; 13 = best age for women to learn about R.H. (from
personal experience, shame led her to hide her period from her mother for 1 year); "Edu. in this
country is weak" (when sit with girls here, surprised--"they don't know anything"); How to solve:
schools, tv (sahhii), drs (must talk on this subject), improved reading; "We must teach our mothers to
talk to her kids", girls talk amongst selves - don't ask? s; Boys must be edu. too (men still virgins
too...prob. on wedding night)
Became pregnant a second time, lost the child; learned more about family planning because of
pregnancy complications
Two eldest children each have 3 kids of their own now (2 girls, 1 boy each); Ask for her advice--> told
them 3 was enough, encouraged them not to have more ("Life is changing, day by day")
"In this culture, it's important to bring a boy. They told me I needed a boy and should keep having
children, but I didn't listen" (husband supportive of decision to stop after 4, didn't need a boy); Used to
believe that through God's will, everything will be sent to the child; People confused between
stopping(deciding to have no more children) and planning(right with Islam); Jordanians love many
kids, to your benefit--more kids = "like an army" (protect you when you're older); Daughter(20)
engaged, should learn about f.p. when married; Couple sits down (before marriage) to discuss f.p.-when to have 1st child (3 yrs); Daughter knows about pills but cannot discuss with fiance yet; Best
place to learn about f.p./C. is from a doctor/health center; Daughter will find own doctor when married
Best time to learn about family planning at age 17/18 (an age where girls can understand; after
coming of period, before marriage); Best place to learn about reproductive health--school and home
(mother will tell you the truth)
M003
yes, TV commercials
U003
yes, good campaign; easy to
teach low-educated people
Pharmacist, Jordan University
JA01
yes, very little (MoH came to
house last wk, 2nd visit)
Pharmacist, Jabal Amman; Was taught very well in the university, but even if university educated, if
doesn't learn sciences will not learn about R.H.
yes, feels they need extended
family involvement in
commercials (not couple's
decision, but mothers and
mother-in-laws)
Uteran Fibroid formed during 1st preg--caused complications during others (fibroids and PID common
among Arab women); In rural communities, everything related to Israel (conspiracy theories about
C./vitamins); Families love kids, push parents to keep having children--not couple's decision
when/how many to have; Woman gets worth from kids (feel have to keep prod--> (percieved as all
she does; if stops having kids, looks lazy); Poor families have many kids (uneducated), most have 8-9
kids; 1 man has 4 wives, 30 children--doesn't even know their names ("Everyone looks at him like
he's a 'real man'"); After many preg, women breastfeed for shorter periods, then become preg again;
Comment on Bedouin comm-->preg not planned/intended, not using C.
R001
Husband supportive of decision to stop after this child, doesn't need more children
Appendix A: Questionnaire
Women’s Attitudes toward Birth Spacing & Contraception
* Denotes a question for married women only
1. In what area do you live in Amman?
2. Do you work or study outside your home?
3. Do you consider yourself a religious person? [Which religion do you practice?]
4. How old are you?
5. Are you married?
6. How old were you when you were married?*
7. Do you have any children? How old are they?*
8. Did you breastfeed your children? For how long?*
9. Do you want to have [more*] children? If so, do you want to wait a while?
10. How many children would you like to have?
11. Were each of your pregnancies planned?* (Did you want to become pregnant?)
12. Are you familiar with ‘birth spacing’ and family planning?
a. If no, skip to question 15.
13. What methods of birth spacing are you familiar with?
14. Where did you learn about these methods? When did you first learn about reproductive
health and family planning?
15. Are you familiar with the ‘sahhii’ (healthy) birth spacing commercials on television?
16. What is your overall opinion about ‘birth spacing’/ family planning?
17. [When married,] would you ever consider using a form of contraception/ birth spacing?
i. Why or why not?
ii. Which ones?
18. Have you ever used a method of ‘birth spacing’/contraception?* Are you currently using
one?*
19. Would you feel comfortable talking to your husband about birth spacing?* Other women?
20. Would you feel comfortable talking to a doctor about birth spacing methods? [Have you?*]
21. Is your doctor a man or a woman? Would this make a difference?
22. Do you know if your doctor/ health clinic offer birth spacing methods?
23. Do you know where you could get them if they didn’t?
24. Do you feel they are affordable?*
25. Where do you feel women should learn about reproductive health? At what age?
Appendix B
Arabic to English Transliteration as Used During Interviewing
Positive Connotations (used in all interviews)
Birth Spacing
Moba’adat al-Hamel
Reproductive Health
Al-saHah al-Injahbeeah
Family Planning (lit. Organization of Pregnancy)
TenDheem il-Usrah
Negative Connotations (avoided during interview)
Sexual Health
Al-saHah al-Jinseeah
Limiting Birth
TaHdeed il-Nessil
*Contraception (lit. Prevention of Pregnancy)
Mena’ al-Hamel
*Denotes that word was used during interviews with translator, as a more complete
explanation could be given.
Works Cited
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Bernhart, M. and Shteiwi, M. The Contraception-Adoption Process in Jordan, CMS Jordan and
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The Noble Qur’an, University of Southern California Muslim Student Association,
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